-
Research ArticlePrevalence of Anemia among Older AdultsResiding
in the Coastal and Andes Mountains in Ecuador:Results of the SABE
Survey
Carlos H. Orces
Laredo Medical Center, Department of Medicine, 1700 East
Saunders, Laredo, TX 78041, USA
Correspondence should be addressed to Carlos H. Orces;
[email protected]
Received 10 December 2016; Revised 29 January 2017; Accepted 6
February 2017; Published 21 February 2017
Academic Editor: Francesc Formiga
Copyright © 2017 Carlos H. Orces. This is an open access article
distributed under the Creative Commons Attribution License,which
permits unrestricted use, distribution, and reproduction in any
medium, provided the original work is properly cited.
Objectives. To estimate the prevalence of anemia and its
determinants among older adults in Ecuador.Methods. The present
studywas based on data from the National Survey of Health,
Wellbeing, and Aging. Hemoglobin concentrations were adjusted
byparticipants’ smoking status and altitude of residence, and
anemia was defined according to theWorld Health Organization
criteria(
-
2 Current Gerontology and Geriatrics Research
(Encuesta Nacional de Salud, Bienestar, y
Envejecimiento)conducted between 2009 and 2010. This survey is a
prob-ability sample of households with a least one person aged60
years or older residing in the Andes Mountains andcoastal regions
of Ecuador. In the primary sampling stage,a total of 317 sectors
from rural areas ( 200 ng/mL serves to confirm that anemia is not
relatedto iron deficiency [15, 16]. Consequently, older adults
withthese ferritin cut-off levels were classified as having
irondeficiency anemia and anemia of chronic disease, respec-tively.
Creatinine clearance (CrCl) was calculated accordingto the
Cockroft-Gault equation and subjects with a CrCl< 30mL/min were
classified as having anemia of chronickidney disease [3, 17]. In
the present analysis, a CRP level ≥5mg/L was the cut-off used to
define low grade inflammation[18]. Vitamin B
12deficiency was defined as serum B
12levels
< 200 pg/mL and hypoalbuminemia as a serum
albuminconcentration < 3.5 g/dL [3, 19].
2.4. Statistical Analysis. Chi-square for categorical
variablesand 𝑡-test for continuous variables were used to
comparethe characteristics of the participants by gender. The
crudeprevalence of anemia stratified by sociodemographic andhealth
characteristics of participants and the MCV distribu-tion according
to selected causes of anemia were presentedas percentages.
Moreover, gender-specific logistic regressionmodels adjusted for
age, race, residence, literacy, and smokingstatus were created to
examine the associations betweendemographic characteristics and
health status of the partic-ipants and anemia. Results of the
multivariate model arepresented as odds ratios (OR) with their 95%
confidenceintervals (95% CI). All analyses used sample weights
toaccount for the complex survey design and to report
anemiaprevalence nationwide. Statistical analyses were
performedusing SPSS, version 17 software (SPSS Inc., Chicago,
IL).
3. Results
A total of 2,372 subjects with amean age of 71.8 (SD 8.2)
yearshad their hemoglobin measured, representing an estimated1.1
million older adults residing in the coastal and AndesMountains
regions in Ecuador. As shown in Table 1, theage, area of residency,
and race of participants were similarlydistributed by gender. In
general, higher proportions ofmen were smokers, literate, and
reported good to excellenthealth. In contrast, women had higher
rates of obesity,ADL’s limitations, cognitive impairment, and
comorbidities.Laboratory data revealed no significant gender
differencesregarding CRP, albumin, and ferritin concentrations.
How-ever, vitamin B
12levels were considerably lower among
men. As shown in Figure 1, women tended to have lower
-
Current Gerontology and Geriatrics Research 3
Table 1: Demographic and health characteristics of participants
in the SABE survey.
Men(𝑛 = 1, 065)
Women(𝑛 = 1, 307) 𝑃 value
Age groups (years), % .48060–69 47.5 46.270–79 31.6 34.5≥80 20.9
19.3
Race, % .881Indigenous 10.0 11.1Black 3.8 3.4Mestizo 70.6
69.1Mulatto 3.8 3.3White 11.8 13.1
Area of residency, % .149Urban Andes Mountains 28.3 30.8Urban
coast 36.1 37.5Rural Andes Mountains 20.2 20.3Rural coast 15.4
11.4
Literacy, % 76.7 64.7
-
4 Current Gerontology and Geriatrics Research
Hemoglobin (g/dL)MenWomen
<10
≥16
10.0
–10.9
11.0
–11.9
12.0
–12.9
13.0
–13.9
14.0
–14.9
15.0
–15.9
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
40.0
45.0
(%)
Figure 1: Hemoglobin concentrations among older adults
inEcuador, SABE II survey.
hemoglobin concentrations than those in men. For instance,58.5%
of women had hemoglobin concentrations less than13 g/dL as compared
with 25.2% in men. However, only 2.1%and 1.6% of women andmen had
hemoglobin levels less than10 g/dL, respectively.
Overall, 20.0% of women aged 60 years and olderwere defined as
having anemia in Ecuador. Nevertheless,the prevalence of anemia
among women was particularlyincreased in blacks and residents from
the urban coast.More-over, subjects with certain health conditions
such as beingunderweight, chronic kidney disease, hypoalbuminemia,
andiron deficiency had significant higher anemia prevalencerates.
After adjustment for potential confounders, hypoal-buminemia,
chronic kidney disease, being underweight, andiron deficiency were
variables independently associated with5.1-, 4.4-, 2.4-, and
2.1-fold increased odds of having anemiaamong older women,
respectively (Table 2).
Anemia was prevalent in 25.2% of older men in Ecuador.Moreover,
the prevalence of anemia in men increased withadvancing age and was
higher among those residing in theurban coast as compared with
residents from other areasof the country. Likewise, subjects with
hypoalbuminemia,those diagnosed with cancer, and participants
defined ashaving chronic kidney disease, iron deficiency, and
lowgrade inflammation had higher prevalence of anemia thanthose who
did not. Notably, after adjustment for covariates,older men with
hypoalbuminemia and those diagnosed withcancer were 6.8 and 6.5
times more likely to have anemia ascomparedwith thosewithout
hypoalbuminemia, respectively(Table 3).
Figure 2 shows the distribution of nutritional and
non-nutritional causes of anemia in older Ecuadorians.
Amongnutritional anemias, iron deficiency was the leading causeof
anemia in 21.8% of men and 16.3% of women, whereas13.5% of men and
6.6% of women had low vitamin B
12
concentrations. Although chronic kidney disease was asso-ciated
with increased odds of having anemia in both genders,
5.2
13.5
21.824.2
31.6
7.2 6.6
16.3
22.7
35.1
Chro
nic k
idne
ydi
seas
e
Vita
min
B12
defic
ienc
y
Iron
defi
cien
cy
Ane
mia
of c
hron
icdi
seas
e
Low
gra
dein
flam
mat
ion
MenWomen
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
40.0
(%)
Figure 2: Selected causes of anemia among older adults in
Ecuador,SABE survey.
only 5.2% of men and 7.2% of women were classified ashaving
anemia of chronic kidney disease. Of interest, 24.2%of men and
22.7% of women had ferritin levels > 200 ng/mL,which is highly
suggestive of anemia of chronic disease.Of relevance, one-third of
older adults with anemia hadevidence of low grade inflammation.
Table 4 shows the MCVdistribution among older adults with anemia in
Ecuador. Ingeneral, 88% of subjects with anemia had a normal
MCVindex. In general, normocytic anemia was predominantlyseen in
participants with kidney disease, chronic disease,and low grade
inflammation. Moreover, 13.9% of men and14.7% of women with iron
deficiency anemia had evidence ofmicrocytosis. On the contrary, a
macrocytic morphology waspresent in only 3.1% of subjects with
vitamin B
12deficiency.
4. Discussion
The present results indicate that anemia represents a mod-erate
public health problem among older adults in Ecuadoraccording to the
WHO criteria (prevalence from 20.0% to39.9%) [12]. Overall, one in
five subjects aged 60 years andolder was defined as having anemia
in Ecuador. Moreover,increased anemia prevalence rates were
predominantly seenwith advancing age, in men, black women, and
subjectsresiding in the urban coast. Interestingly, the
geographicdistribution of anemia found in the present study
contrastwith those results previously reported by Cañizares et al.
inthe 1980s in which a significant higher prevalence of anemiawas
described in the rural areas of the country [7]. It maybe
postulated that the increased prevalence of anemia amongolder
adults in urban areas of the country may be explainedby changes in
the demographic distribution of the populationover time. For
instance, the percentage of adults aged 65years and older who lived
in the urban areas of the country
-
Current Gerontology and Geriatrics Research 5
Table 2: Prevalence of anemia among older women in Ecuador.
Characteristics Crude prevalence OR (95% CI)∗
Age groups (years), %60–69 17.8 (14.0, 22.2) 1.0070–79 20.5
(16.5, 25.3) 1.17 (1.15, 1.19)≥80 24.1 (18.7, 30.5) 1.37 (1.35,
1.40)
Race, %Indigenous 19.0 (11.6, 29.7) 0.69 (0.68, 0.71)Black 42.4
(24.4, 62.7) 2.19 (2.12, 2.27)Mestizo 17.8 (14.9, 21.1) 0.66 (0.64,
0.67)Mulatto 24.5 (11.5, 44.6) 0.91 (0.87, 0.94)White 25.3 (18.3,
33.8) 1.00
Area of residency, %Urban Andes Mountains 18.4 (14.3, 23.4) 1.58
(1.54, 1.62)Urban coast 22.5 (18.3, 27.3) 1.94 (1.89, 1.99)Rural
Andes Mountains 20.8 (15.0, 28.1) 1.67 (1.63, 1.72)Rural coast 14.2
(9.1, 21.6) 1.00
Literacy, %Yes 19.5 (16.6, 22.7) 1.00No 20.8 (16.2, 26.2) 1.09
(1.08, 1.11)
Smoking, %Current 32.8 (16.7, 54.2) 1.80 (1.75, 1.86)Former 19.6
(13.4, 27.8) 0.99 (0.97, 1.01)Never 19.5 (16.7, 22.5) 1.00
BMI (kg/m2), %Underweight 34.5 (19.1, 54.1) 2.41 (2.31,
2.51)Normal 28.5 (23.0, 34.6) 2.14 (2.10, 2.18)Overweight 14.9
(11.5, 19.0) 0.96 (0.94, 0.98)Obesity 16.1 (12.2, 21.0) 1.00
Self-reported health, %Excellent to good 13.1 (9.1, 18.4)
1.00Fair to poor 21.8 (18.8, 25.1) 1.97 (1.93, 2.00)
ADL’s limitations, %Yes 24.0 (19.2, 29.6) 1.43 (1.41, 1.45)No
18.3 (15.4, 21.5) 1.00
Cognitive impairment, %Yes 24.3 (18.1, 31.7) 1.44 (1.42, 1.47)No
18.4 (15.6, 21.5) 1.00
DiabetesYes 22.6 (16.9, 29.4) 1.25 (1.24, 1.27)No 19.3 (16.5,
22.4) 1.00
Cancer, %Yes 21.0 (10.7, 37.0) 1.15 (1.13, 1.19)No 20.0 (18.1,
23.7) 1.00
COPD, %Yes 13.0 (6.0, 26.1) 0.54 (0.52, 0.55)No 20.7 (18.1,
23.7) 1.00
Heart disease, %Yes 22.9 (15.5, 32.5) 1.27 (1.25, 1.29)No 19.4
(16.8, 22.2) 1.00
-
6 Current Gerontology and Geriatrics Research
Table 2: Continued.
Characteristics Crude prevalence OR (95% CI)∗
Arthritis, %Yes 22.3 (18.1, 27.2) 1.52 (1.50, 1.54)No 18.4
(15.3, 21.8) 1.00
CRP (mg/L), %
-
Current Gerontology and Geriatrics Research 7
Table 3: Prevalence of anemia among older men in Ecuador.
Characteristics Crude prevalence OR (95% CI)∗
Age groups (years), %60–69 19.5 (15.1, 24.9) 1.0070–79 27.9
(22.4, 34.1) 1.56 (1.54, 1.59)≥80 34.2 (26.8, 42.6) 1.81 (1.78,
1.84)
Race, %Indigenous 15.6 (8.7, 26.4) 0.63 (0.61, 0.65)Black 26.3
(14.1, 43.9) 1.01 (0.97, 1.05)Mestizo 26.7 (22.6, 31.3) 1.16 (1.14,
1.19)Mulatto 19.5 (9.7, 35.1) 0.65 (0.62, 0.68)White 24.9 (16.0,
36.7) 1.00
Area of residency, %Urban Andes Mountains 23.3 (17.8, 29.9) 0.94
(0.92, 0.96)Urban coast 30.4 (24.3, 37.2) 1.42 (1.40, 1.45)Rural
Andes Mountains 19.3 (14.5, 25.3) 0.86 (0.84, 0.88)Rural coast 24.5
(17.4, 33.5) 1.00
Literacy, %Yes 23.6 (20.0, 27.7) 1.00No 30.7 (23.9, 38.7) 1.34
(1.32, 1.36)
Smoking, %Current 24.8 (17.5, 33.8) 1.12 (1.10, 1.14)Former 26.2
(21.5, 31.6) 1.10 (1.08, 1.11)Never 23.6 (18.8, 29.2) 1.00
BMI (kg/m2), %Underweight 35.0 (18.5, 56.1) 1.55 (1.48,
1.63)Normal 29.5 (24.4, 35.1) 1.49 (1.45, 1.52)Overweight 18.7
(14.3, 24.2) 0.82 (0.80, 0.84)Obesity 19.0 (11.8, 29.3) 1.00
Self-reported health, %Excellent to good 18.2 (13.6, 23.9)
1.00Fair to poor 28.2 (24.1, 32.7) 1.65 (1.62, 1.67)
ADL’s limitations, %Yes 36.1 (28.8, 44.2) 1.71 (1.69, 1.74)No
22.0 (18.5, 26.0) 1.00
Cognitive impairment, %Yes 34.6 (26.0, 44.5) 1.76 (1.72, 1.79)No
21.9 (18.4, 25.8) 1.00
DiabetesYes 25.6 (17.7, 35.6) 1.04 (1.02, 1.06)No 25.2 (21.7,
29.0) 1.00
Cancer, %Yes 68.0 (42.8, 85.7) 6.53 (6.27, 6.80)No 24.2 (21.0,
27.8) 1.00
COPD, %Yes 28.6 (18.4, 41.5) 1.07 (1.04, 1.10)No 24.9 (21.5,
28.6) 1.00
Heart disease, %Yes 21.9 (14.6, 31.7) 0.65 (0.64, 0.67)No 25.7
(22.2, 29.6) 1.00
Arthritis,%Yes 29.8 (22.5, 38.3) 1.29 (1.27, 1.31)No 24.0 (20.5,
28.0) 1.00
-
8 Current Gerontology and Geriatrics Research
Table 3: Continued.
Characteristics Crude prevalence OR (95% CI)∗
CRP (mg/L), %30 23.8 (20.5, 27.4) 1.00≤30 57.3 (37.8, 74.8) 2.98
(2.86, 3.11)
Albumin (g/dL), %≥3.5 24.4 (21.1, 28.0) 1.00
-
Current Gerontology and Geriatrics Research 9
of macrocytic anemia. Likewise, Loikas et al. demonstratedin a
population-based study among older from Finland thatthe presence of
macrocytosis or macrocytic anemia did notincrease the odds of
having vitamin B
12deficiency, which is
consistent with the present results [34].Interestingly,
one-third of older Ecuadorians with anemia
had evidence of low grade inflammation. Nonnutritionalanemia in
older adults has been documented to result froman interaction
between an increased inflammatorymilieu andage-related
comorbidities. Among the inflammatory mark-ers, IL-6 leads to
iron-limited hematopoiesis with increasedhepcidin levels and poor
iron incorporation into the devel-oping erythrocytes. In addition,
tumor necrosis factor 𝛼,in a different pathway, leads to
erythropoietin resistanceof the hematopoietic stem cells,
increasing its demand andeventually exceeding the ability of the
kidney to maintainadequate levels to sustain normal hemoglobin
[15].
The present study has several limitations that should
bementioned. First, because of the cross-sectional study design,the
association of anemia with certain demographic andhealth
characteristics does not necessarily indicate causation.Second, the
evaluation of nutritional and nonnutritionalanemia should be
considered preliminary. For instance, ironand vitamin B
12anemia were defined exclusively according
to ferritin and vitamin B12
levels available in the SABEsurvey, respectively. Moreover,
other potential causes ofanemia affecting older adults such as
folate deficiency andmyelodysplastic syndromes requiring
cytogenetic and bonemarrow analyses were not evaluated in the
present study [34].Third, most of the participant’s comorbidities
and lifestylevariables were self-reported, which may be a source of
recallbias. Fourth, the present findings may be only generalizedto
older adults residing in the coastal and Andes Mountainsregions of
the country. Despite these limitations, the presentstudy reports
national estimates of anemia among olderadults.
In conclusion, anemia is a prevalent condition amongolder adults
in Ecuador. Moreover, further research is neededto examine the
association between anemia and adversehealth-related outcomes among
older Ecuadorians.
Competing Interests
The author declares that there is no conflict of
interestsregarding the publication of this paper.
References
[1] D. Lipschitz, “Medical and functional consequences of
anemiain the elderly,” Journal of the American Geriatrics Society,
vol. 51,no. 3, pp. S10–S13, 2003.
[2] B. W. J. H. Penninx, M. Pahor, R. C. Woodman, and J.
M.Guralnik, “Anemia in old age is associated with
increasedmortality and hospitalization,” Journals of Gerontology,
Series A:Biological Sciences and Medical Sciences, vol. 61, no. 5,
pp. 474–479, 2006.
[3] J. M. Guralnik, R. S. Eisenstaedt, L. Ferrucci, H. G. Klein,
andR. C. Woodman, “Prevalence of anemia in persons 65 yearsand
older in the United States: evidence for a high rate of
unexplained anemia,” Blood, vol. 104, no. 8, pp.
2263–2268,2004.
[4] H. Gaskell, S. Derry, R. Andrew Moore, and H. J.
McQuay,“Prevalence of anaemia in older persons: systematic
review,”BMC Geriatrics, vol. 8, article no. 1, 2008.
[5] L. Ferrucci, R.D. Semba, J.M.Guralnik et al.,
“Proinflammatorystate, hepcidin, and anemia in older persons,”
Blood, vol. 115, no.18, pp. 3810–3816, 2010.
[6] W. B. Freire, K. M. Silva-Jaramillo, M. J.
Ramı́rez-Luzuriaga, P.Belmont, and W. F. Waters, “The double burden
of undernutri-tion and excess body weight in Ecuador,”The American
Journalof Clinical Nutrition, vol. 100, no. 6, pp. 1636S–1643S,
2014.
[7] C. Cañizares, R. Bonilla, and C. Vásquez, “Prevalence
ofdifferent types of anemia in Ecuador,” Brazilian Journal
ofMedical and Biological Research, vol. 21, no. 4, pp. 767–772,
1988.
[8] http://www.eclac.cl/celade/proyecciones/basedatos BD.htm.[9]
http://www.ecuadorencifras.gob.ec/encuesta-de-salud-biene-
star-del-adulto-mayor/.[10] M. G. Icaza and C. Albala,
Minimental State Examina-
tions (MMSE) del studio de la demencia en Chile:
AnálisisEstadı́stico—Serie Investigaciones en Salud
Pública-DocumentosTécnicos, Coordinación de Investigaciones,
División de Salud yDesarrollo Humano, OPS, 1999,
http://www.paho.org.
[11] A.Menke, S. Casagrande, L. Geiss, andC.C. Cowie,
“Prevalenceof and trends in diabetes among adults in the United
States,1988–2012,” JAMA, vol. 314, no. 10, pp. 1021–1029, 2015.
[12] http://apps.who.int/iris/bitstream/10665/85839/3/WHO NMHNHD
MNM 11.1 eng.pdf.
[13] M. H. Bross, K. Soch, and T. Smith-Knuppel, “Anemia in
olderpersons,”American Family Physician, vol. 82, no. 5, pp.
480–487,2010.
[14] G. H. Guyatt, C. Patterson, M. Ali et al., “Diagnosis of
iron-deficiency anemia in the elderly,” The American Journal
ofMedicine, vol. 88, no. 3, pp. 205–209, 1990.
[15] N. Berliner, “Anemia in the elderly,” Transactions of the
Amer-ican Clinical and Climatological Association, vol. 124, pp.
230–237, 2013.
[16] G.Weiss and L. T. Goodnough, “Anemia of chronic
disease,”TheNew England Journal of Medicine, vol. 352, no. 10, pp.
1011–1023,2005.
[17] D. W. Cockcroft and M. H. Gault, “Prediction of
creatinineclearance from serum creatinine,”Nephron, vol. 16, no. 1,
pp. 31–41, 1976.
[18] W. P. J. Den Elzen, J. Gussekloo, J. M. Willems et al.,
“Predictivevalue of low ferritin in older persons with anemia with
andwithout inflammation: the Leiden 85-plus study,” Journal of
theAmerican Geriatrics Society, vol. 58, no. 8, pp. 1601–1603,
2010.
[19] M. E. Salive, J. Cornoni-Huntley, J. M. Guralnik et al.,
“Anemiaand hemoglobin levels in older persons: relationship with
age,gender, and health status,” Journal of the American
GeriatricsSociety, vol. 40, no. 5, pp. 489–496, 1992.
[20] Y. Domı́nguez, C. Zurita, D. Calvopiña, J. Villaćıs, and
M.Mora, “Prevalence of common hemoglobin variants in an
afro-descendent Ecuadorian population,” BMC Research Notes, vol.6,
no. 1, article no. 132, 2013.
[21] W.-H. Pan and J.-P. Habicht, “The
non-iron-deficiency-relateddifference in hemoglobin concentration
distribution betweenblacks and whites and between men and women,”
AmericanJournal of Epidemiology, vol. 134, no. 12, pp. 1410–1416,
1991.
[22] B. W. J. H. Penninx, M. Pahor, M. Cesari et al., “Anemia
isassociated with disability and decreased physical performance
http://www.eclac.cl/celade/proyecciones/basedatos_BD.htmhttp://www.ecuadorencifras.gob.ec/encuesta-de-salud-bienestar-del-adulto-mayor/http://www.ecuadorencifras.gob.ec/encuesta-de-salud-bienestar-del-adulto-mayor/http://www.paho.orghttp://apps.who.int/iris/bitstream/10665/85839/3/WHO_NMH_NHD_MNM_11.1_eng.pdfhttp://apps.who.int/iris/bitstream/10665/85839/3/WHO_NMH_NHD_MNM_11.1_eng.pdf
-
10 Current Gerontology and Geriatrics Research
and muscle strength in the elderly,” Journal of the
AmericanGeriatrics Society, vol. 52, no. 5, pp. 719–724, 2004.
[23] A. Contreras-Manzano, V. de la Cruz, S. Villalpando,
R.Rebollar, and T. Shamah-Levy, “Anemia and iron deficiency
inMexican elderly population. Results from the Ensanut 2012,”Salud
Publica de Mexico, vol. 57, no. 5, pp. 394–402, 2015.
[24] R. M. Bryce, A. Salas, D. Acosta et al., “The
prevalence,correlates and impact of anaemia among older people in
Cuba,Dominican Republic, Mexico, Puerto Rico and Venezuela,”British
Journal of Haematology, vol. 160, no. 3, pp. 387–398, 2013.
[25] C. Fonseca, F. Marques, A. Robalo Nunes, A. Belo, D.
Brilhante,and J. Cortez, “Prevalence of anaemia and iron deficiency
inPortugal: the EMPIRE study,” Internal Medicine Journal, vol.
46,no. 4, pp. 470–478, 2016.
[26] C. B. Bowling, L. A. Inker, O. M. Gutiérrez et al.,
“Age-specificassociations of reduced estimated glomerular
filtration ratewith concurrent chronic kidney disease
complications,”ClinicalJournal of the American Society of
Nephrology, vol. 6, no. 12, pp.2822–2828, 2011.
[27] D. C. Rockey and J. P. Cello, “Evaluation of the
gastrointestinaltract in patients with iron-deficiency anemia,” New
EnglandJournal of Medicine, vol. 329, no. 23, pp. 1691–1695,
1993.
[28] G. Campuzano-Maya, “Hematologic manifestations of
Heli-cobacter pylori infection,” World Journal of
Gastroenterology,vol. 20, no. 36, pp. 12818–12838, 2014.
[29] S. P. Stabler, “Vitamin B12 deficiency,” New England
Journal ofMedicine, vol. 368, no. 2, pp. 149–160, 2013.
[30] G. Murphy, S. M. Dawsey, E. A. Engels et al., “Cancer
riskafter pernicious anemia in the US Elderly population,”
ClinicalGastroenterology and Hepatology, vol. 13, no. 13, pp.
2282.e4–2289.e4, 2015.
[31] N. Uemura, S. Okamoto, S. Yamamoto et al.,
“Helicobacterpylori infection and the development of gastric
cancer,” NewEngland Journal of Medicine, vol. 345, no. 11, pp.
784–789, 2001.
[32] R. Carmel, R. Green, D. W. Jacobsen, K. Rasmussen, M.
Florea,and C. Azen, “Serum cobalamin, homocysteine, and
methyl-malonic acid concentrations in a multiethnic elderly
popula-tion: ethnic and sex differences in cobalamin and
metaboliteabnormalities,” American Journal of Clinical Nutrition,
vol. 70,no. 5, pp. 904–910, 1999.
[33] M. Olivares, E. Hertrampf, M. T. Capurro, and D.
Wegner,“Prevalence of anemia in elderly subjects living at home:
role ofmicronutrient deficiency and inflammation,” European
Journalof Clinical Nutrition, vol. 54, no. 11, pp. 834–839,
2000.
[34] S. Loikas, P. Koskinen, K. Irjala et al., “Vitamin B12
deficiencyin the aged: A Population-Based Study,”Age and Ageing,
vol. 36,no. 2, pp. 177–183, 2007.
-
Submit your manuscripts athttps://www.hindawi.com
Stem CellsInternational
Hindawi Publishing Corporationhttp://www.hindawi.com Volume
2014
Hindawi Publishing Corporationhttp://www.hindawi.com Volume
2014
MEDIATORSINFLAMMATION
of
Hindawi Publishing Corporationhttp://www.hindawi.com Volume
2014
Behavioural Neurology
EndocrinologyInternational Journal of
Hindawi Publishing Corporationhttp://www.hindawi.com Volume
2014
Hindawi Publishing Corporationhttp://www.hindawi.com Volume
2014
Disease Markers
Hindawi Publishing Corporationhttp://www.hindawi.com Volume
2014
BioMed Research International
OncologyJournal of
Hindawi Publishing Corporationhttp://www.hindawi.com Volume
2014
Hindawi Publishing Corporationhttp://www.hindawi.com Volume
2014
Oxidative Medicine and Cellular Longevity
Hindawi Publishing Corporationhttp://www.hindawi.com Volume
2014
PPAR Research
The Scientific World JournalHindawi Publishing Corporation
http://www.hindawi.com Volume 2014
Immunology ResearchHindawi Publishing
Corporationhttp://www.hindawi.com Volume 2014
Journal of
ObesityJournal of
Hindawi Publishing Corporationhttp://www.hindawi.com Volume
2014
Hindawi Publishing Corporationhttp://www.hindawi.com Volume
2014
Computational and Mathematical Methods in Medicine
OphthalmologyJournal of
Hindawi Publishing Corporationhttp://www.hindawi.com Volume
2014
Diabetes ResearchJournal of
Hindawi Publishing Corporationhttp://www.hindawi.com Volume
2014
Hindawi Publishing Corporationhttp://www.hindawi.com Volume
2014
Research and TreatmentAIDS
Hindawi Publishing Corporationhttp://www.hindawi.com Volume
2014
Gastroenterology Research and Practice
Hindawi Publishing Corporationhttp://www.hindawi.com Volume
2014
Parkinson’s Disease
Evidence-Based Complementary and Alternative Medicine
Volume 2014Hindawi Publishing
Corporationhttp://www.hindawi.com
